Provider Demographics
NPI:1194050989
Name:DELUCO, JOANNA M (OD)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:M
Last Name:DELUCO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:14915 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-8504
Mailing Address - Country:US
Mailing Address - Phone:269-781-9863
Mailing Address - Fax:269-781-9864
Practice Address - Street 1:14915 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-8504
Practice Address - Country:US
Practice Address - Phone:269-781-9863
Practice Address - Fax:269-781-9864
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004545152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
383687790Medicare UPIN